Dr. Joseph Merlino on sexuality, insanity, Freud, fetishes and apathy

Joseph Merlino: "If [a person] is just hurting himself, is it a problem? In our society we would take the position that it is, because we can't understand why someone would..."photo: David Shankbone

You may not know Joseph Merlino, but he knows about you and what makes you function. He knows what turns you on and he knows whether it is a problem for you. Merlino, who is the psychiatry adviser to the New York Daily News, is one of the more accomplished psychiatrists in his field and he is the Senior Editor of the forthcoming book, Freud at 150: 21st Century Essays on a Man of Genius. The battle over interpreting Freud's legacy still rages, a testament to the father of psychoanalysis and his continuing impact today.

Dr. Merlino posits that absent structural, biochemical or physiological defects, insanity and pathology are relative and in flux with the changing culture of which you are a part. So it is possible to be sane and insane all in one day if, for instance, you are gay and fly from the United Kingdom to Saudi Arabia.

What is normal and what is insane?

DS: How do we know what is normal and what is insane?

JM: That is part of what moved psychiatry and the psychoanalytic field to where it is currently, and that is the value and appreciation for societal values. It's not like definitions of normality and pathology were handed down on some tablet that spelled out what those things are. It is largely defined by society and culture. We, as a profession, have to incorporate that as practitioners in that society and culture. For example, something in our society might not be a problem, but it might be in another culture or society.

DS: And that would be considered insanity?

JM: In some societies homosexuality is still considered pathology, where here it is mostly not.

DS: So insanity is always relative to a society?

JM: To some degree, I think it is. Not where there are underlying physiological problems; for example, severe depressions have biochemical changes, such as in serotonin levels, and schizophrenics have differences in the way their brains processes information along with blood flow and other changes in various brain areas. These are where it is more black and white. Most societies would see those as mental illnesses.

The question is when does it come to the attention of practitioners and when does it become a problem, and that varies greatly by society. For example, if you are on a farming society in an area that is not very populated, an individual might not be considered schizophrenic, but just odd. They may be accepted within a family structure and tolerated within the community. In our culture and society it is more difficult for an individual like that to survive without coming to the attention of an authority where they are put into treatment.

DS: So eccentricity would be a form of insanity in principle, relative to whatever society found it eccentric, since it is a violation of social norms and mores?

JM: It would bring the person to the attention of whoever it is in that society that dictates what is pathology and normality—

JM: Yes, it's a value judgment. Insanity has a pejorative connotation as opposed to saying someone is ill.

DS: So a woman who goes walking down the street naked in the middle of Manhattan, but fully cognizant of it and doing it to elicit a reaction, she has a pathology?

JM: Well, she is going to come to the attention of authorities who are going to question whether she has pathology or not. Certainly, she is bucking the cultural norm, and chances are the individual is going to be picked up by the police, taken to the station, and then probably be brought to a psychiatric emergency room for an evaluation to determine whether or not she is disordered.

DS: How often are people who are considered to have a mental disorder or pathology aware that their behavior is thought of as problematic by other people?

JM: It's a challenge for them. Take the most extreme, say someone who is grossly psychotic. More often, they are not aware that their behavior is problematic to society and that is what gets them into difficulties. Other individuals who are more aware usually are on the personality disorder realm of diagnoses. Even there, people with personality disorders are comfortable with what they are doing; the problem is, what I cause you.

DS: Such as a person who has an anger management problem? The problem isn't that they are brought to anger, it's the external influences. Even though that they know anger is not a preferable state to be in, they don't see themselves as the problem, even though they know that people get them there is a problem. In other words, my anger is not good, but the real problem is that you made me angry.

JM: The challenge is getting them to realize how their own behavior is a problem for other people. If somebody has an anger management issue that they are not aware of, but they are constantly having fights with their spouse, they are getting fired from jobs, their kids aren't talking to them...this is creating distress if not in the individual, certainly in their family. The goal there is to get the individual to realize he or she is creating a problem, and get them to identify what that problem is and to take steps to ameliorate it.

DS: The declassification of homosexuality as a mental disorder was a controversial debate in the psychiatric community, and it is still presented 30 years later as if it is this raging debate, and that it is just activism that was the impetus for change as opposed to any real hard science.

JM: It's true! It was. It was activism. But there was not hard science to say that homosexuality was a disorder or an illness, and that was the reason why activists took aim at psychiatry and psychoanalysis and challenged them to come up with the data to support that position. And they couldn't! The only data they could come up with were psychoanalytic theories that were not data. The data that they called data was presented from small groups of clinical populations of people who are gay who didn't like or didn't want or couldn't accept being gay. That was the population from which this so-called data was extracted. What the gay activists did in the 1970's was pull out the true data, the scientific data that they could find, and presented it to the diagnosis committee of the American Psychiatric Association and persuaded them that the science that did exist was on the side of homosexuality not being a disease or a disorder. That is why the diagnosis committee--the Nomenclature Committee, which is what it was called--suggested to the Board of the American Psychiatric Association that it be removed, and it was.

DS: If the issue was presented today, would it be 58% still, or would it be a greater number that do not believe homosexuality is a mental illness?

JM: I think so. There are still clusters of holdouts who believe--and it's traditionally a psychoanalysts who still see it as a disorder--but those people who are really dwindling. In fact, one of the last leaders of that movement, Charles Socarides, died a few years ago. I think that particular view is dying out.

DS: But it still has credence?

JM: It still has credence in groups that consider themselves scientists, but really aren't. It's more of a religious movement. I think we've come full circle. Psychiatry thinking there is something wrong with being homosexual really came out of the Judeo-Christian movement for the past 2,000 years. We moved away from that and to organized medicine through psychiatry, taking the position that it's not an evil in terms of the individual; it's an illness. The thinking it was a problem of the individual came from the psychoanalytic movement, which held sway in American psychiatry through the 1950's. American psychiatry beforehand never took up the issue of homosexuality; it was never even something that was thought about in terms of was it an illness or wasn't it an illness? It was just presumed, it was accepted it was an illness. Until that was challenged in the late 1960's, early 1970's.

Sigmund Freud

JM: Freud was somewhat of a maverick in that regard, because his position really went against what a lot of other people were saying. Freud maintained that bisexuality was a normal part of development. That all of us went through a period of bisexuality and that, in the end, most of us came out heterosexual but that the bisexual phase we traversed remained on some unconscious level, and was dealt with in other ways. For instance, friendship, chumships, and 'greater glory of the love of mankind' kinds of sentiments. Freud felt these had their basis in this constitutional bisexuality that all individuals had. He did not consider it something that should be criminalized, or penalized—

DS: —but treated?

JM: —treated if it presented a problem for the individual. Freud felt there were a number of homosexuals he encountered who did not have a variety of complex problems that homosexuality was a part of. He found people who were totally normal in every other regard except in terms of their sexual preference. In fact, he saw many of them as having higher intellects, higher aesthetic sensibilities, higher morals; those kinds of things. He did not see it as something to criminalize or penalize, or to keep from psychoanalytic training. A lot of the psychoanalytic institutes felt if you were homosexual you should not be accepted; that was not Freud's position.

DS: How did he discern whether a person's homosexuality was a problem with the person internally, or whether it was an external problem brought about by societal reaction to the individual?

JM: Freud would use the technique of analysis to figure that out, and work with that individual to explore the cause. In his later theories he would look at whether this is an oedipal issue, whether he wanted to be with the mother and couldn't have the mother so he then wanted to have men, so that men could would like him, and then he would get the affection of the mother object. He would explore the issues that way. He would not start from the bias that this is the individual's problem that needed to be fixed.

JM: I think you used the operative word. It's a model. What we try to do as therapists is come up with a hypothesis that works for the individual that he can use to help him or herself, as opposed to having my theory inflicted upon you. If you can use a psychosexual development kind of model in helping to understand what the situation is, it can be a language that the two of us can speak. Most therapists are focusing less on even using that as language. It's more of a concept to structure something.

JM: I think we have to cede ground on that. As a psychiatrist who is analytically trained, I like to think of myself as a dynamic psychiatrist. Meaning that I use some of the theories that we have talked about to help inform my approach to a patient, but I importantly also consider my medical and psychiatric knowledge. In the case of OCD, the preferred treatments are often medication and cognitive behavioral therapy. I recently worked with an OCD individual, at the insistence of his behavior therapist who wanted me to help the individual figure out why he was having a hard time accepting medication. In the end, frankly, I referred him back to the behavioral therapist because our treatment wasn't going anywhere.

JM: It's a complex question and I do not have an easy answer. I think some of it is political, some of it is provocative, and some of it is genuine. I think that there are people who are naturally feminine. We all come in different flavors and colors, and it's the same in terms of our personality tributes, whether male or female. There are some heterosexual women who are more masculine, and some heterosexual men who are more feminine. The same with gay men. In addition to that, some of it is a provocative stance, certainly earlier on back when it was more of a 'fuck you' attitude than it might need to be today. For example, drag queens or the front of the gay pride parade, which is more of a very in-your-face, we are here, we are comfortable with who we are, and we can be as provocative as we can be because we are who we are, and we are entitled to be this way.

DS: Chris Crocker, the YouTube celebrity known for his in-your-face femininity, perhaps falls in that category.

JM: Look at the other side of it, some of the rappers who epitomize raw masculinity in an in-your-face kind of way, and I would see that as the other end of the spectrum, but doing a similar thing. A 'fuck you' kind of attitude, 'I have the right to be who I am' kind of thing. There's a whole spectrum, and most of us fall in the middle.

DS: What is the process by which a person develops a gender?

JM: It's complex. Part of it is genetic endowment. Nature versus nurture. Part of it is what we come from, who we come from, and that, together with the environment in which we grow. For example, we can have a genetic endowment that predisposes us towards femininity, but we are nurtured in a family that is extremely orthodox, 'you're a boy, so you're going to be a man.' That kid may grow up to be a rather straight, but conflicted, kind of individual. A macho kind of guy, or a macho gay guy, may have some conflict around the environment he grew up in. I think it's an amalgam of genetics, our environment we grow up in, and whatever experiences we come across along the way. That's what fine tunes that individual into what he or she will become.

DS: Do you think there are psychological distinctions between sadism and masochism in men?

JM: Clearly there's a distinction between what those individuals do, but what do you mean by psychological distinctions?

DS: Freud assumed sadism in men resulted from a distortion of an aggressive component of male sexual instinct, whereas masochism in men was seen as an aberration, completely contrary to the nature of male sexuality. Is that still a function of psychoanalysis?

JM: For some, it is the psychological need to dominate, for others the need to be dominated. Others vacillate between both domination and submission. Part of it is rooted in biology. We may be born with a tendency towards—let's call it 'problem' for a moment—and let's say someone is sadomasochistic. It's a problem only if it is getting that individual into difficulties, if he or she is not happy with it, or it's causing problems in their personal or professional lives. If it's not, I'm not seeing that as a problem. But assuming that it did, what I would wonder about is what is his or her biology that would cause a tendency toward a problem, and dynamically, what were the experiences this individual had that led him or her toward one of the ends of the spectrum.

DS: What is the motivation behind S&M? Pain for sexual pleasure? Gratification from cruelty? Pleasure from power and the absence thereof?

JM: It's all of those things. It's an individual kind of thing. I think all of us have a little S&M in us. We don't all go around wearing leather, but—

JM: —yes. I think all of us want to explore and do these different things, and that is all perfectly normal within a consensual relationship. Obviously, if I go out and rape somebody, it's a problem. But if it's in the confines of a relationship and it is something that stimulates both people, they enjoy it, and it spices up their life, then it's fine.

[A follow-up note from Dr. Merlino: The above discussion assumes S&M is a consensual sexual relationship. The gamut of behavior can run from healthy and normal to disturbed and pathological. Clearly sadism in the context of the detached inflicting of pain on others based on the belief one has the right to do so and that others are there to be abused (e.g. rapists, batterers, etc) is pathological. Similarly, masochistic behavior rooted in depression or a self-defeating personality make-up is pathological.]

Paraphilias, urges and fetishes

JM: Paraphiliac is a general term for a lot of different sexual deviancies, for example, fetishism, or pedophilia or voyeurism. It's the blurring of what I might do that is a turn-on for me, and what might get me into problems with others. Once you cross that line, it exists as a problem. If I come up to your apartment and peer in your window while you are getting undressed, it's a problem for you and it will end up a problem for me. I will be labeled a voyeur, and therefore it's a problem.

It's cross-dressing, but is it a pathology?photo: David Shankbone

DS: Can a person be a paraphiliac and not have it be a problem?

JM: No, because the term itself is a diagnosis and if you look at the current listing of diagnoses, the one thing you will find as a qualifier on every one of them for it to be considered a disorder is that it must interfere with functioning, personal interrelationships, career, etc. Absent that, we can't give it a diagnosis. So Giuliani gets dressed up, we don't say he has a disorder.

JM: When it creates a problem for that individual. For instance, I'm a cross-dresser and I don't want to keep it confined to my circle of friends, or my party circle, and I want to take that to my wife and I don't understand why she doesn't accept it, or I take it to my office and I don't understand why they don't accept it, then it's become a problem because it's interfering with my relationships and environment.

DS: So pathology is almost always defined in relation to your interaction with the outside world? If I lived on an island I could just do anything I wanted and nothing would be a pathology because I am a person unto myself and it doesn't affect anyone else?

JM: I don't think that's exactly right. Take an example of a schizophrenic individual, or a self-cutter, who is tormented by voices who are telling him to hurt himself. If he hurts others we say it's a problem. If he is just hurting himself, is it a problem? In our society we would take the position that it is, because we can't understand why someone would—we aren't talking about just sex play, where you might inflict a little pain to enjoy an erotic experience, or things of that sort—but if somebody is actually attempting to take his life or severely injure himself, or multiple self-cutting, we would fall back on a somewhat paternalistic position and say, 'Wait a minute, this is crossing the line, and this is a disorder because we are judging it is hurtful to yourself.' We would judge that a disorder.

DS: What about autoerotic asphyxiation where a person engages in that activity that can be highly dangerous—fatal—yet they don't believe it? Is it a 'smoker's denial'?

JM: I think so. Somebody going into that who doesn't consider it a serious threat to himself is somebody who is not informed. It could have a very lethal outcome. It's a pathology, strictly engaging in that, like someone who wants to play Russian Roulette to have the excitement of hearing a click, but the bullet is not coming out. That's a disorder because it has the potential for lethality or serious injury.

DS: With obsessions such as paraphilias, a person presents things to themselves in a series of questions. What if I'm really gay? What if I really want to seduce my patient? What if I really was aroused by a picture of that child? If someone comes to you and says, 'I just can't get out of my head the thought that I want to kill my baby', how do you handle such a challenging problem?

JM: It is very challenging. Obviously, the risk of potential outcome judges how intense the intervention has to be. For example, someone who is thinking a lot about wanting to kill his or her child, that is a very serious thing. An evaluation would have to look very carefully at what is the likelihood of such a thing happening, is it really a symbolic way of expressing something? For example, 'Susie pissed me off so much I could kill her.' As opposed to having a vision of slashing her throat, burning her body and tossing her into the ocean. That would be considered a very serious concern.

DS: The difference is between having a thought occur, and actually acting it out in one's head? It's "I thought about wanting to kill my baby," versus, "I'm picturing drowning my baby in the bathtub almost every night I wash her."

JM: Yes, that is the very important differential. Many of us have all kinds of thoughts, like the seduction of a student by a teacher, or those kinds of things. We have them, it's part of our humanity. The taboo nature makes it alluring. But it's when the person fears losing control, and the ability to control the thinking. There's a very big difference between a thought and an action.

DS: I have a personal example that makes me laugh. There is a 60-year-old woman at work named Barbara who I have never met, but to whom I have spoken on the phone. I don't know many Barbaras, but I remember the opening scene of Night of the Living Dead where the brother and sister are in the cemetery and to give the sister, Barbara, a scare, the brother starts going, "Baahbarah, Baaahbarah, they are coming to get you, Barbara." It makes me laugh to imagine a scenario of calling this 60-year-old Barbara at work and saying that into the phone. I have acted this out many, many times with my office mates, and it makes us laugh. It's making me laugh now, the thought of doing something that bizarre—

JM: [Laughs] —And behind this is what?

DS: Behind it is the idea...I would never...

JM: Barbara's the boss?

DS: No, she's just another co-worker, who I've never even met. We've just spoken on the phone once. She has a kind voice. But I have acted this out in my head often, as a way to give myself a chuckle. To actually do it would be mortifying. It might scare her and I wouldn't want to do that.

JM: Maybe you would. That's what Freud would say. There's a dynamic behind that, which is not so easily apparent, but when you think about it or you analyze it, there might be some reason behind it. Or Barbara might actually be a stand-in for somebody else that you really would like to have somebody from the living dead come and...

DS: [Laughs] But would that be a pathology, that I've acted this harassing phone call out in my head? And if it's not a problem, is it because the act is relatively harmless, as opposed to wanting to drown my baby?

JM: No. You are enjoying it, you are laughing about it, it's doing something for you. It's not causing anybody pain or grief. It's not like you are staying up nights worrying about Barbara is going to see your name and you are going to lose your job, and you can't eat anymore. Based on this scenario...it's a joke! But as Freud would say, jokes aren't just jokes. They have a meaning. And if you can get beyond that and understand it, you might learn something that's a little different than what you are saying. There might be a meaning.

DS: Such as, why do I find violating a social norm or more amusing?

JM: Yeah. It might be particular to Barbara, or who 'Barbara' represents. When you talk about Night of the Living Dead there's a connection immediately there to this person and this wish.

DS: Is there always a connection? For instance, just that opening of the movie sticks in my head and I don't meet many Barbaras. It was just something that popped into my head, synapses fired. And that movie did play a role in my life, trust me. But would it always signify something deeper than that?

JM: An orthodox analytic position would be that there is always something deeper than that. I think practically, sometimes a cigar is just a cigar.

Cultural psychology in the United States today

DS: Have you noticed any affect that the current political culture has had on your patients, in terms of the Iraq War? Either in pathologies where the war is manifesting itself, or in just a general discomfort with the state of the culture and society as it is?

JM: I can't say based upon my practice; I keep a very small talking practice, because of my other work. Based on my own personal engagement with the outside world, I think people are very frustrated, annoyed, mistrustful, and non-believing of anything government says, but not to the point of doing anything about it.

DS: What do you mean when you say 'doing anything about it'?

JM: Being activists about it. I don't know if it's learned helplessness or what. There's apathy. One of the most energized moments I experienced in years was when there were the large protests of marchers down the east side to the U.N. I long for the play Hair to come back. It's 40 years old now. I don't understand why it's not back on Broadway.

DS: We have been in this war for four years. Is it important to discuss it?

JM: I think a lot of us lead more and more isolated existences in the midst of millions of people. We're on our cell phone. We're on our Blackberry. We're on our computer. It's all disjointed in some kind of a way.

DS: Do you think people are putting their heads in the sand, or do you think it is too much for people to process what is happening?

JM: I think people feel impotent. Look, people came out and did this massive election, turned over Congress, the House, the Senate, and nothing has changed. I think people are feeling that if the vote is the thing is going to change society, and it's not even doing that... Or you have to be a multi-millionaire to run for the office. With a clean record--who has that? The jury system, and mistrust of that of whether it is bought off, who gets justice and who doesn't get justice.

DS: But we respond to it.

JM: Until the Mets lose a game, and then we are on to that. We are trained to have very short attention spans. We have become isolated and disjointed from one another, except when we have to mix.

DS: How do you think that affects personality development, that our interactions today are so two-dimensional?

JM: It affects a lot of things. Relationships, how we get along with each other. You look at something like 9/11 or a disaster, and how that galvanizes and brings people together and how short-lived that is. Then it goes back down again. It's as if we constantly need a jolt of that magnitude to shake us out of our complacency in the ways we live and interact. I think it's sad, and it's a concern.

DS: It seems a lot of pathology comes from people being isolated, living in their own heads and coming up with their own theories absent the interaction of other people. They develop entire systems of beliefs and what they think motivates other people.

JM: I think it's a lack of direction. It's different, because the same individual who might be someone with a very eastern, Buddhist kind of approach to something, might be very grounded, gratified, fulfilled and feel very healthy. There's a direction, an inward sort of peace, as opposed to the ennui of a directionless state that a lot of people are in today, unless it's the television giving it to us, or the iPod, or the Internet.

*About Joseph Merlino

Dr. Joseph Merlino is Director of Psychiatry and Behavioral Health at Queens Hospital Center. He is Clinical Professor of Psychiatry at the Mount Sinai School of Medicine and Adjunct Professor of Psychiatry and Behavioral Sciences at New York Medical College, where he is also Supervising and Training Analyst. He is a Distinguished Fellow of the American Psychiatric Association, a Fellow of The American Academy of Psychoanalysis & Dynamic Psychiatry, and a member of the Group for the Advancement of Psychiatry and the American College of Psychiatrists. Dr. Merlino is the immediate Past-President of the American Academy of Psychoanalysis and Dynamic Psychiatry, one of the nation's four major psychoanalytic organizations. He is Senior Editor of Freud at 150: 21st Century Essays on a Man of Genius, due to be published October 28 by Jason Aronson Press, and is co-editor of American Psychiatry & Homosexuality, recently published by Haworth Press. Dr. Merlino is also an expert consultant with The Forensic Panel in New York City. He is the former director of community and ambulatory psychiatry at Bellevue Hospital Center, the oldest public hospital in the United States. Dr. Merlino lectures and has published in the areas of applied psychoanalysis and medical ethics. He is in private practice in Manhattan.